Health Assessment Exam I
While assessing a 48-year-old client's near vision, the nurse can anticipate the client will state that her vision is: A) blurred. B) clouded. C) 20/20. D) clear.
A) blurred. Explanation: Visual problems with close objects occur more frequently after the age of 40.
The nurse is interviewing a client to obtain the health history. Which question would the nurse ask first? A) "Are you having any pain?" B) "What brings you here today?" C) "What medications do you normally use?" D) "Do you have any allergies?"
B) "What brings you here today?" Explanation: The first subject usually discussed in a client interview is the client's specific reason for seeking care, commonly called the "chief complaint" or "chief concern." Other questions (e.g., about pain, medications and allergies) would be used as the client interview continues.
A nurse is performing an integumentary assessment for a group of clients. Which of the following findings should the nurse recognize as requiring immediate intervention? A. Pallor B. Cyanosis C. Jaundice D. Erythema
B. Cyanosis The priority finding when using the airway, breathing, circulation (ABC) approach to care is cyanosis, which is an indication of hypoxia (inadequate oxygenation). Therefore, the nurse should immediately report this finding to the provider.
When using an otoscope to assess the tympanic membrane of an adult, the nurse straightens the ear canal by gently pulling the pinna in which direction? a) Up and back b) Down and forward c) Away from the examiner d) In any direction
a) Up and back The ear canal of an adult is straightened by gently pulling the pinna of the ear up and back. In children younger than 3 years of age, the ear canal is straightened by pulling the pinna gently down and back.
A nurse caring for patients in a long-term care facility is performing a functional assessment of a new patient. Which questions would the nurse ask? Select all that apply. a) Are you able to dress yourself? b) Do you have a history of smoking? c) What is the problem for which you are seeking care? d) Do you prepare your own meals? e) Do you manage your own finances? f) Whom do you rely on for support?
a, d, e A functional health assessment focuses on the effects of health or illness on a patient's quality of life, including the strengths of the patient and areas that need to improve. The nurse would assess the patient's ability to perform ADLs and IADLs such as dressing, grooming, preparing meals, and managing finances.
A patient's visual acuity is assessed as 20/40 in both eyes using the Snellen chart. The nurse interprets this finding as: a) The patient can see twice as well as normal. b) The patient has double vision. c) The patient has less than normal vision. d) The patient has normal vision.
c) The patient has less than normal vision. Normal vision is 20/20. A finding of 20/40 would mean that a patient has less than normal vision.
Ms. Elaine Quan is a 34-year-old Chinese American who has been hospitalized for the past 3 days with a diagnosis of hepatitis B. The nurse is planning a head-to-toe assessment of the client and understands that the characteristics of an acute hepatitis infection are jaundice, nausea and vomiting, joint pains, rashes, and elevations in serum liver function tests. Where would be the best location for the nurse to observe jaundice in this client? a) The face and hands b) The neck and chest c) The sclera of the eye d) The mucous menbranes of the mouth
c) The sclera of the eye
After inspecting the skin of a patient, the nurse documents the presence of a skin lesion as a palpable solid mass measured at 1 cm. What types of skin lesions might this describe? Select all that apply. a) Macule b) Patch c) Plaque d) Nodule e) Bulla f) Pustule
c, d Plaque and nodules are palpable, elevated, solid masses that may measure 1 cm. Macules and patches are circumscribed, flat, nonpalpable changes in skin color. Macules are less than or equal to 1 cm and patches are greater than 1 cm. Bulla and pustules are circumscribed, superficial skin elevations formed by free fluids in a cavity with skin layers. Bulla are greater than 0.5 cm and pustules are filled with pus.
The nurse is asking admission interview questions and the client has explained the reason for seeking care. What is the most appropriate way to document the response? a) Client describes shortness of breath and increased sputum production. b) Client reports respiratory distress and frequent spitting. c) Client reports breathlessness and productive cough. d) Client states, "I feel winded all of the time and yesterday I started spitting up a lot of phlegm."
d) Client states, "I feel winded all of the time and yesterday I started spitting up a lot of phlegm." The client's reason for seeking care should always be stated in the client's own words.
Which components are included in the integumentary system? Select all that apply. A) Hair B) Skin C) Muscles D) Sweat glands E) Nails F) Arteries
A) Hair B) Skin D) Sweat glands E) Nails Explanation: The integumentary system includes the skin, hair, nails, sweat glands, and sebaceous glands. Arteries are included in the cardiovascular or peripheral vascular systems, and muscles are included in the musculoskeletal system.
A nurse is examining a client and is testing the client's cranial nerves. Which action would the nurse use to evaluate cranial nerve III? Select all that apply. A) Visual acuity B) Visual fields C) Pupillary reaction to light D) Blink reflex E) Ability to open and close eyelids
C) Pupillary reaction to light E) Ability to open and close eyelids Explanation: Cranial nerve III is the oculomotor nerve. It is a motor nerve that is involved with pupil constriction and raising the eyelids. The nurse would test the pupillary reaction to light and the client's ability to open and close eyelids. Visual field and visual acuity testing would be used to evaluate cranial nerve II or the optic nerve. Blink reflex is not used to test the cranial nerves.
A nurse is caring for a client with paraplegia. Using observation to examine the client's skin, what finding might indicate the presence of a pressure injury? A) An intact red area on the buttocks. B) An area of swollen, pale red bumps on the front of the neck. C) A circular red, scaly area that itches on the top of the forearm arm. D) An intact faded purple area on the shoulder blades, with a yellowish tint.
A) An intact red area on the buttocks. Explanation: An intact reddened area of the skin in an area that comes in contact with a wheelchair may be a stage I pressure injury. The shoulder blades would be another area of contact for the wheelchair, but a faded purple area indicates a resolving bruise. The neck and forearm are not pressure areas for a paraplegic. Pale red bumps indicate urticaria (hives), while circular red scaly area indicates ringworm.
The nurse is palpating the skin of a 30-year old client and documents that when picked up in a fold, the skin fold slowly returns to normal. What would be the next action of the nurse based on this finding?. A) Assess the client for dehydration. B) Assess the client for cardiovascular disorders C) Report the finding as a positive sign for cystic fibrosis. D) Document a normal skin finding on the client chart.
A) Assess the client for dehydration.Explanation:Turgor is the fullness or elasticity of the skin. The client should be further assessed for signs and symptoms of dehydration because poor skin turgor is a sign of dehydration. When the client is dehydrated, the skin's elasticity is decreased, and the skin fold returns slowly. Poor skin turgor is neither a sign of cardiovascular disease nor cystic fibrosis.
The nurse is caring for an 88-year-old male admitted 2 days ago for dehydration. The nurse brings the client his breakfast tray and notes that the client appears to be having difficulty understanding what she is saying to him today. Which nursing action is most appropriate? A) Check the client's ear canals for cerumen. B) Use facial expressions and sign language to communicate. C) Ask the client if he left his earplugs in his ears. D) Speak to the older adult client in a high-frequency tone of voice.
A) Check the client's ear canals for cerumen. Explanation: Ear wax (cerumen) becomes drier in older adults and can block the ear canal and cause decreased hearing. Asking the client if he has earplugs in his ears is not appropriate. Using facial expressions and sign language is appropriate in communicating with the hard of hearing, but this client's hearing loss was acute and requires further assessment. When speaking to older adults who are hearing-impaired, one needs to use low tones to facilitate communication; high-frequency tones are problematic for older adults.
A client is admitted to the emergency department. He is bleeding from a cut on his head and his skin color is pale, with diaphoresis. What nursing action should be performed first? A) Evaluate the blood pressure and pulse B) Provide a warm, quiet, dimly lit room C) Assess the cause of the client's wound D) Interview to obtain the health history
A) Evaluate the blood pressure and pulse Explanation: In this acute-care emergency situation, the nurse should assess the pulse and blood pressure, since the client seems to be presenting with signs and symptoms of shock.
The nurse is assessing a child for an underactive thyroid gland. Which assessment technique would the nurse use? A) Palpation B) Inspection C) Percussion D) Auscultation
A) Palpation Explanation: The thyroid gland is palpated for size, shape, symmetry, tenderness, and the presence of any nodules. If palpable, the thyroid gland should feel soft but elastic. Hypothyroidism may be caused by a goiter, which is an enlarged thyroid gland. Inspection, percussion, and auscultation would not reveal an enlarged thyroid gland.
The nurse is assessing the ear canal and tympanic membrane of a client using an otoscope. Which finding would the nurse document as normal? A) The tympanic membrane is translucent, shiny, and gray. B) The ear canal is rough and pinkish. C) The ear canal is smooth and white. D) The tympanic membrane is reddish.
A) The tympanic membrane is translucent, shiny, and gray. Explanation: The tympanic membrane should be intact, translucent, shiny, and gray. The ear canal should be smooth and pink.
When a client enters the acute care facility, the nurse should perform a: A) comprehensive health assessment. B) physical health assessment. C) focused health assessment. D) spiritual health assessment.
A) comprehensive health assessment. Explanation: A comprehensive health assessment encompasses the physical, psychological, social, and spiritual dimensions of living.
The nurse is performing a head and neck assessment for a client. When inspecting the face, the nurse notes that the skin, sclera, and mucous membranes appear yellowish. In the electronic medical record the nurse chooses which drop-down box selection to document this finding? A) jaundice B) cyanosis C) pallor D) erythema
A) jaundice Explanation: Jaundice is a yellow color of the skin resulting from elevated amounts of bilirubin in the blood; it is associated with liver and gallbladder disease, some types of anemia, and excessive hemolysis (breakdown of red blood cells). Erythema refers to redness of the skin and is caused by dilation of superficial blood vessels. Pallor refers to paleness of the skin and often results from a decrease in the amount of circulating blood or hemoglobin, causing inadequate oxygenation of the body tissues. Cyanosis is a bluish or grayish discoloration of the skin in response to inadequate oxygenation.
Palpation is the use of hands and fingers to gather information through touch. Different parts of the hand are more suitable for different tactile sensations. Which part of the hand is best for sensing temperature? A) the dorsum B) the knuckles C) the fingertips D) the palm
A) the dorsum Explanation: The skin over the dorsum of the hand is sensitive to temperature because it is thin and its nerve density is great. The palm of the hand is sensitive to vibration and is useful in locating a vibration associated with a heart murmur. The fingertips are concentrated with nerve endings and can sense fine difference in texture and consistency. The knuckles are not used in palpation.
A nurse has explained her intention to conduct a Weber test and a Rinne test. Which pieces of equipment will the nurse require? A) tuning fork B) ophthalmoscope C) otoscope D) Snellen chart
A) tuning forkExplanation:Rinne and Weber tests are performed in order to assess sound conduction; both require a tuning fork. A Rinne test evaluates hearing loss by comparing air conduction to bone conduction. The nurse strikes a tuning fork and places it on the mastoid bone behind one ear. When the client can no longer hear the sound, they signal to the nurse. The nurse then moves the tuning fork to the ear canal. When the client can no longer hear that sound, they once again signal the nurse. The nurse records the length of time the client hears each sound. In the Weber test, the nurse strikes a tuning fork and places it on the middle of the client's head, and the client indicates where the sound is best heard: the left ear, the right ear, or both equally. A Snellen chart is an eye chart that can be used to measure visual acuity. An otoscope is an instrument designed for visual examination of the eardrum and the passage of the outer ear, typically having a light and a set of lenses. An ophthalmoscope is an instrument for inspecting the retina and other parts of the eye.
When using an otoscope to assess the tympanic membrane of an adult, the nurse straightens the ear canal by gently pulling the pinna in which direction? A)Up & Back B)Down & Froward C)Away from the examiner D)In any direction
A)Up & Back The ear canal of an adult is straightened by gently pulling the pinna of the ear up and back. In children the ear is pulled back and down
Which technique should the nurse use to assess the pupillary light reflex on a client? A. Bring a narrow beam of light from the temple toward the eye, observing for direct and consensual pupillary constriction. B. Ask the client to follow the penlight in six directions and observe for bilateral pupil constriction. C. Have the client focus on a distant object, then ask the client to look at the penlight being held about 4 cm from the nose and observe for pupil constriction. D. Use an ophthalmoscope to focus light on the sclera and observe for a reflection on each eye.
A. Bring a narrow beam of light from the temple toward the eye, observing for direct and consensual pupillary constriction To test the pupillary light reflex, the nurse should advance a light in from the temple and note the direct and consensual pupillary constriction. The diagnostic positions test and test for accommodation will not provide the pupillary reflex information.
A nurse in a provider's office is preparing to assess a client's skin as part of a comprehensive physical exam. Which of the following findings should the nurse expect? (Select all that apply) A. Capillary refill less than 3 seconds B. 1+ pitting edema in both feet C. Pale nail beds in both hands D. Thick skin on the soles of the feet E. Numerous light brown macules on the face
A. Capillary refills less than 3 seconds D. Thick skin on the soles of the feet [AND palms of hands] E. Numerous light brown macules on the face [such as freckles] NOT B or C: The nurse should not expect pitting edema, which can reflect excess fluid that has accumulated in the body tissues; The nurse should not expect pallor in the nail beds, which can reflect anemia or impaired circulation
The nurse enters the room of an older adult client diagnosed with Alzheimer disease to perform a head-to-toe assessment. What assessment findings by the nurse are reflective of the normal signs of aging? Select all that apply. A. Decreased near vision B. Decreased facial hair C. Increased gag reflex D. Increased systolic and diastolic BP E. Decreased tissue elasticity F. Increased mental confusion
A. Decreased near vision D. Increased systolic and diastolic BP E. Decreased tissue elasticity Decreased near vision (presbyopia), increased systolic and diastolic blood pressure, and decreased tissue elasticity are normal signs of aging. Decreased facial hair, increased gag reflex, and increased mental confusion are not normal signs of aging.
A nurse is assessing a client's thyroid gland as part of a comprehensive physical exam. Which of the following findings should the nurse expect? (Select all that apply) A. Palpating the thyroid in the lower half of the neck B. Visualizing the thyroid on inspection of the neck C. Hearing a bruit when auscultating the thyroid D. Feeling the thyroid ascend as the client swallows E. Finding symmetric extension off the trachea on both sides of the midline
A. Palpating the thyroid in the lower half the neck D. Feeling the thyroid ascend as the client swallows E. Finding symmetric extension off the trachea on both sides of the midline NOT B or C: An avg size thyroid gland is not visible on inspection; A bruit indicates increased bood flow, possibly due to hyperthyroidism
A parent of a school-age child is told that her child has normal vision. The school nurse explains that the child's vision is: A) 20/40 or 6/12. B) 20/20 or 6/6. C) 20/200 or 6/60. D) 20/60 or 6/18.
B) 20/20 or 6/6. Explanation: Normal vision is at or near 20/20 or 6/6, full field of vision, and tricolor vision (red, green, blue).
A nurse is teaching a client about the importance of checking the skin for changes that might suggest skin cancer. After describing the typical lesions associated with melanoma, the nurse determines that the teaching was successful when the client identifies which characteristic? Select all that apply. A) Symmetrical shape B) Change in the mole C) Larger than 1/4 inch in diameter D) Single color E) Irregular edges
B) Change in the mole C) Larger than 1/4 inch in diameter E) Irregular edges Explanation: The lesions of melanoma are asymmetrical (that is, if a line is drawn through a mole, the two halves will not match) with uneven or irregular borders and a variety of colors or shades within the lesion. The size is larger in diameter than the size of the eraser on a pencil (1/4 inch or 6 mm), but they may sometimes be smaller when first detected. The lesions are evolving, which means that any change—in size, shape, color, elevation, or another trait, or any new symptom such as bleeding, itching, or crusting—points to danger.
A nurse performs an assessment on a client who has been admitted to a long-term care facility for physical rehabilitation. What is the term for this type of assessment? A) Ongoing assessment B) Comprehensive assessment C) Emergency assessment D) Focused assessment
B) Comprehensive assessment Explanation: A comprehensive assessment with a detailed health history and complete physical examination are usually conducted when a client enters a health care setting. An ongoing and focused assessment is conducted at regular intervals during client care. An emergency assessment is a rapid, focused assessment conducted to determine potentially fatal situations
When assessing a "PT" eye, which instrument would the nurse use to visualize the retina? A) Otoscope B) Ophthalmoscope C) Stethoscope D) Tuning Fork
B) Ophtalmoscope Only the ophtalmoscope is used to assess the internal eye.
The nurse has performed a Romberg test in the context of a client's neurologic assessment. The client has failed the test. The nurse should consequently identify what nursing diagnosis? A) Chronic Confusion B) Risk for Falls C) Acute Confusion D) Disturbed Thought Processes
B) Risk for Falls Explanation: Romberg test assesses balance; an unsuccessful test constitutes a likely risk for falls. This test does not relate to the client's cognition.
Upon assessment of a client with myasthenia gravis, the nurse observes drooping of the upper eyelids. This finding is known as: A) miosis. B) ptosis. C) entropion. D) ectropion.
B) ptosis. Explanation: Ptosis is drooping of the upper lids and is an abnormal finding. Inward turning of the lower lid is termed entropion. Outward turning of the lower lid is termed ectropion. Miosis is constriction of the pupil, which is often caused by medications.
A nurse is gathering equipment needed for a basic physical assessment. Which supplies will be required? Select all that apply. A) stethoscope B) tongue blade C) ophthalmoscope D) drapes E) cotton balls
B) tongue blade D) drapes A) stethoscope Explanation: For a basic physical assessment, the nurse needs gloves, an examination gown, cloth or paper drapes, a scale, a stethoscope, a sphygmomanometer, a thermometer, a pen light or flashlight, a tongue blade, an assessment form, and a pen. The nurse does not need cotton balls or an ophthalmoscope.
A nurse is assessing an adult client's ear canals with an otoscope as part of a head and neck exam. Which of the following action should the nurse take? (Select all that apply) A. Pull the auricle down and back B. Insert the speculum slightly down and forward C. Insert the speculum 2 to 2.5cm (0.8 to 1in.) D. Make sure the speculum does not touch the ear canal E. Use the light to visualize the TM in a cone shape
B. Insert the speculum slightly down and forward D. Make sure the speculum does not touch the ear canal E. Use the light to visualize the tympanic membrane in a cone shape NOT A or C: The nurse should pull the auricle up and back for adults and down and back for children younger than 3 years; The nurse should insert the speculum 1 to 1.5 cm (0.4 to 0.6 in.)
A nurse is assessing an older adult client who has significant tenting of the skin over his forearm. Which of the following factors should the nurse consider as a cause for this finding? (Select all that apply) A. Thin, parchment-like skin B. Loss of adipose tissue C. Dehydration D. Diminished skin elasticity E. Excessive wrinkling
B. Loss of adipose tissue C. Dehydration D. Diminished skin elasticity NOT A or E: The older adult client as aging occurs will have skin that becomes thin and translucent and is not a factor for tenting of the skin; The older adult client who has aging skin does become wrinkled, but is not a factor for tenting of the skin
To assess an adult client's hearing, the nurse performs the Rinne test by activating the tuning fork and placing it first at the: A. front of the ear B. mastoid process C. top of the head D. affected ear
B. mastoid process
The nurse is assessing the skin of a veteran who has returned from deployment in the middle east. Which statement by the nurse reflects the best strategy to gain cooperation of the client? A) "I am going to look at your skin now." B) "I need to look at your skin to see if you have any problems." C) "May I look at your skin to determine if there are any issues?" D) "Take off your clothes so I can look at your skin."
C) "May I look at your skin to determine if there are any issues?" Explanation: Asking permission to look at the client's skin and explaining why prepares the client for the assessment and may gain the clients cooperation. The nurse will need to consider the possibility of posttraumatic stress disorder (PTSD) or other emotional issues related to the client's military service. By directing the client and not explaining the assessment it is likely the client will resist the nurse.
A nurse is completing a vision exam with the Snellen eye chart and records the client's vision as 20/30 or 6/9. The client asks the nurse, A) "What does that mean?" How should the nurse respond? B) "Your vision is better than average; you can read from 30 ft (9 m) what a person with normal vision can read from 20 ft (6 m)." C) "You are able to read at 20 ft (6 m) what a person with normal vision can read at 30 ft (9 m)." D) "Your vision is perfect; you can read the entire chart, and you do not need glasses." E) "Your vision in your right eye is slightly different than that of your left eye."
C) "You are able to read at 20 ft (6 m) what a person with normal vision can read at 30 ft (9 m)." Explanation: The first number indicates the distance the person is standing from the chart; the second number gives the distance at which a normal eye can see it. It is not appropriate or correct to tell the client that vision is perfect, that one eye is better than the other, or that vision is better than average.
A grating feel and noise with joint movement, particularly in the temporomandibular joint, is called what? A) Fremitus B) Inflammation C) Crepitus D) Arthritis
C) Crepitus Explanation: Problems with the temporomandibular joint include pain or a grating feeling called crepitus.
A nurse is preparing to conduct a basic physical assessment of a client who has just been admitted to the unit. What equipment will the nurse require in order to perform this assessment? A) Bladder scanner B) Syringe C) Penlight or flashlight D) Doppler ultrasound
C) Penlight or flashlight Explanation: A penlight or flashlight is necessary to gauge pupillary response and to visualize the client's mouth. Doppler ultrasound, a bladder scanner and a syringe are not necessary in order to perform a basic physical assessment.
During assessment of the lower extremities, the nurse notes the bilateral lower extremities are pink, intact, warm, and soft to touch, as well as normal in contour with a 4 mm depression in the skin after pressing that returns after 2 seconds. Which is the correct interpretation and documentation of this result? A. bilateral lower extremities within normal limits B. 1+ pitting edema noted on bilateral lower extremities C. 2+ pitting edema noted on bilateral lower extremities D. brawny edema noted over bilateral lower extermities
C. 2+ pitting edema noted on bilateral lower extremities Depression of the skin with pressing is an abnormal finding. 2+ pitting edema is a deeper pit after pressing (4 mm) and lasts longer than 1+ pitting edema, but the lower extremities are fairly normal contour. Brawny edema occurs when fluid can no longer be displaced secondary to excessive interstitial fluid accumulation, and there is no pitting, so the tissue palpates as firm or hard and the skin surface is shiny, warm, and moist.
A nurse is conducting an assessment of a patient's cranial nerves. The nurse asks the patient to raise the eyebrows, smile, and show the teeth to assess which cranial nerve? A. Olfactory B. Optic C. Facial D. Vagus
C. Facial Motor function of the facial nerve (cranial nerve VII) is assessed by asking the patient to raise the eyebrow, smile, and show the teeth. The olfactory nerve (cranial nerve I) is tested by testing smell reception with various agents. The nurse tests the optic nerve (cranial nerve II) for acuity and visual fields and the vagus nerve (cranial nerve X) by asking the patient to swallow and speak, noting hoarseness.
A nurse is performing a head and neck exam for an older adult client. Which of the following age-related findings should the nurse expect? (Select all that apply) A. Reddened gums B. Lowered vocal pitch C. Tooth loss D. Glare intolerance E. Thickened eardrums
C. Tooth loss D. Glare intolerance E. Thickened eardrums NOT A or B: The nurse should expect an older adult's gums to be pale; The nurse should expect an older adult's vocal pitch to rise
Which technique should the nurse use to assess the pupillary light reflex on a client? A) Use an ophthalmoscope to focus light on the sclera and observe for a reflection on each eye. B) Have the client focus on a distant object, then ask the client to look at the penlight being held about 4 cm from the nose and observe for pupil constriction. C) Ask the client to follow the penlight in six directions and observe for bilateral pupil constriction. D) Bring a narrow beam of light from the temple toward the eye, observing for direct and consensual pupillary constriction.
D) Bring a narrow beam of light from the temple toward the eye, observing for direct and consensual pupillary constriction. Explanation: To test the pupillary light reflex, the nurse should advance a light in from the temple and note the direct and consensual pupillary constriction. The diagnostic positions test and test for accommodation will not provide the pupillary reflex information.
A nurse admitting a new client to the hospital needs to determine the client's needs and current problems. What is the priority action of the nurse? A) Contact the health care provider. B) Review the client's past medical records. C) Assist the client with activities of daily living. D) Complete an assessment.
D) Complete an assessment. Explanation: Before the nurse can determine what care a person requires, the nurse must determine the client's needs and problems. This requires the use of assessment skills and data collection, which include interviewing, observing, and examining the client, and in some cases, the client's family. Following the assessment, the nurse can also use the client's medical record and contact other health care providers.
The charge nurse is observing a new nurse perform an assessment of a client's head and neck. Which action, if observed, would require the charge nurse to intervene? A) Occlusion of one of the client's nostrils while the client breathes through the nose B) Warming of a stethoscope before assessing a client's breath sounds C) Placing a tongue blade at the side of the tongue while the client pushes it to the left and right D) Palpation of both carotid arteries at the same time
D) Palpation of both carotid arteries at the same time Explanation: Palpation of both carotid arteries at once can obstruct blood flow to the brain, potentially causing dizziness or loss of consciousness. The other assessments are correct as described.
The nurse is performing an initial admission assessment from a client. What subjective data gathered from the client will the nurse document? Select all that apply. A) Peripheral pulses +3 B) Skin warm and dry C) Hypoactive bowel sounds in all four quadrants D) Reports of abdominal pain of 4 on a 0 to 10 point scale E) Client informs the nurse there is a floater in the left eye F) The client states, "I feel nauseated."
D) Reports of abdominal pain of 4 on a 0 to 10 point scale E) Client informs the nurse there is a floater in the left eye F) The client states, "I feel nauseated." Explanation: Subjective data includes any reports or information that the client gives. These include: Reports of abdominal pain of 4 on a 0 to 10 point scale, The client states, "I feel nauseated", and the client informs the nurse there is a floater in the left eye. Objective data is assessment data that are gathered by the nurse and are inspected, palpated, percussed, or auscultated by the health care team.
The nurse pinches the skin under the clavicle and it tents. What conclusion should the nurse determine from this assessment? A) The skin is less elastic with aging. B) The skin has normal turgor. C) The client is overhydrated. D) The client is dehydrated.
D) The client is dehydrated. Explanation: The nurse assesses for skin turgor by gently pinching the skin under the clavicle. This technique provides information about the client's hydration status as well as skin mobility and elasticity. Skin is less elastic with aging, but the turgor should remain normal (less than 3 seconds) and not tent, or remain in the pinched position. When a client is dehydrated, the skin will tent for more than 3 seconds. When a client is overhydrated, edema will be present with the skin, and the skin turgor would be normal, or taunt because of excess fluid.
A client recently was diagnosed with Bell's palsy and is back to the clinic for a follow-up visit. What would the nurse observe during the assessment of cranial nerve VII if the client's symptoms are resolving? A) The client is able to turn the head to the side and shrug the shoulders against resistance. B) The client's tongue remains midline when it protrudes from the mouth. C) The palate and pharynx move as the client says "ah." D) The movement and appearance would appear symmetrical as the client smiles, frowns, and raises the eyebrows.
D) The movement and appearance would appear symmetrical as the client smiles, frowns, and raises the eyebrows. Explanation: Bell's palsy is usually a temporary condition that presents with left or right facial weakness or paralysis. Cranial nerve VII controls the muscles of the face. Normal results would be symmetrical appearance and movement as the client smiles, frowns, and raises the eyebrows. Swallowing and speaking is demonstrated with cranial nerve X. Cranial nerve XII is assessed with movement of the tongue. The movement of shoulder muscles assesses cranial nerve XI.
A nurse is using the assistance of an interpreter. When interviewing a client who does not speak English, the nurse should: A. assess the client's vital signs first B. interpret the effect of deep palpation C. inspect the symmetry of the facial features D. observe the client's body language
D. observe the client's body lang When using an interpreter, the nurse should observe the cues the client expresses with body language, and listen to the tone of voice.
The nurse is performing an initial assessment on a patient admitted with iron deficiency anemia. Upon inspection of the patient's tongue, the nurse expects to observe which of the following? a) A bright-red tongue b) A white-coating on the tongue c) A black hairy tongue d) A fissured tongue
a) A bright-red tongue A bright-red tongue is often seen in patients with deficiencies in iron, vitamin B12, or niacin. A black, hairy tongue may be a result of antibiotic use. A white coating on the tongue results from an infection, poor oral hygiene, or smoking. A fissured tongue occurs due to dehydration.
Which of the following would be most important for a nurse to do to ensure the accuracy of inspection during assessment? a) Compare bilateral body parts b) Have 20/20 vision c) Focus on selected body systems d) Use touch judiciously
a) Compare bilateral body parts With inspection, a comparison of bilateral body parts is necessary for recognizing abnormal findings. Perfect vision is unnecessary; the nurse examines all body systems and uses touch during palpation.
The nurse is caring for a client who just informed her that he noticed some blood in the toilet after a bowel movement. The nurse assesses the client's anal area and notes a deep linear separation in the skin that extends into the dermis. The nurse recognizes that this skin lesion is characteristic of which of the following? a) Fissure b) Crust c) Erosion d) Ulcer
a) Fissure
During the admission assessment of a new patient, the nurse is now preparing to assess the patient's thyroid gland. How should the nurse perform this assessment? a) Stand behind the patient and palpate the sides of the trachea. b) Lightly percuss slightly off midline over the patient's trachea. c) Auscultate over the patient's trachea while asking the patient to hold his or her breath. d) Observe the midline of the patient's neck while asking him or her to bear down.
a) Stand behind the patient and palpate the sides of the trachea. Assessment of the thyroid gland is performed by palpating each side of the patient's trachea.Percussion, auscultation, and inspection are not central to assessment of the thyroid gland.
During an assessment of the pupils, a beam of light is directed through the pupil and into the retina, which stimulates the cranial nerve III and causes the muscles of the iris to constrict. What is evaluated by doing this? Select all that apply. a) Shape b) Internal structures c) Reaction to light d) Accommodation e) Size f) Visual acuity
a, c, d, e Pupils are evaluated bilaterally for size, shape, accommodation, and reaction to light. Normally, pupils are black, round and they constrict briskly when exposed to a bright light source. One can observe both pupils and estimate initial size and reaction size.
A nurse is assessing a patient's eyes for extraocular movements. Which action correctly describes a step the nurse would take when performing this test? a) Ask the patient to sit about 3 feet away facing the nurse. b) Keep a penlight about 1 foot from the patient's face and move it slowly through the cardinal positions. c) Move a penlight in a circular motion in front of the patient's eyes. d) Ask the patient to cover one eye with a hand or index card.
b) Keep a penlight about 1 foot from the patient's face and move it slowly through the cardinal positions. The steps in testing for extraocular movement are: (1) Ask the patient to sit or stand about 2 feet away, facing the nurse, who is sitting or standing at eye level with the patient; (2) ask the patient to hold the head still and follow the movement of a forefinger or a penlight with the eyes; (3) keeping the finger or light about 1 foot from the patient's face, move it slowly through the cardinal position—up and down, left and right, diagonally up and down to the left, diagonally up and down to the right.
A client has been reporting persistent headaches. Which is an example of subjective data? a) The client is alert and oriented to person, place, and time. b) Pain is 4 out of 10 on a pain scale. c) The client appears lethargic. d) Temperature is 104.1°F (40.05°C)
b) Pain is 4 out of 10 on a pain scale.
A nurse is performing eye assessments at a community clinic. Which assessment would the nurse document as normal? a) The client's pupils dilate when looking at a near object and constrict when looking at a distant object. b) The client's pupils are black, equal in size, and round and smooth. c) The client's eyes do not converge when the nurse moves a finger toward his nose. d) An older adult's pupils are pale and cloudy.
b) The client's pupils are black, equal in size, and round and smooth. The pupils should be black, equal in size, and round and smooth. When an object moves towards the client's nose, the eyes should converge towards the object. Pale and cloudy pupils are indication of a problem such as cataracts. The client's pupils should constrict when looking at a near object and dilate when looking at a distant object.
Which actions would the nurse perform when using the technique of palpation during the physical assessment of a patient? Select all that apply. a) The nurse compares the patient's bilateral body parts for symmetry. b) The nurse takes a patient's pulse. c) The nurse touches a patient's skin to test for turgor. d) The nurse checks a patient's lymph nodes for swelling. e) The nurse taps a patient's body to check the organs. f) The nurse uses a stethoscope to listen to a patient's heart sounds.
b, c, d During palpation, the nurse uses the sense of touch to take a pulse, test for skin turgor, and check lymph nodes. With inspection, a comparison of bilateral body parts is necessary for recognizing abnormal findings. During percussion, the fingertips are used to tap the body over body tissues to produce vibrations and sound waves. The characteristics of the sounds produced are used to assess the location, shape, size, and density of tissues. Auscultation is the act of listening with a stethoscope to sounds produced within the body.
A nurse is assessing a patient's eyes for accommodation. What actions would the nurse perform during this test? Select all that apply. a) Bring a penlight from the side of the patient's face and briefly shine the light on the pupil. b) Hold a forefinger, a pencil, or other straight object about 10 to 15 cm (4″ to 6″) from the bridge of the patient's nose. c) Hold a finger about 6″ to 8″ from the bridge of the patient's nose. d) Darken the room. e) Ask the patient to look straight ahead. f) Ask the patient to first look at a close object, then at a distant object, then back to the close object.
b, f To test accommodation the nurse would hold the forefinger, a pencil, or other straight object about 10 to 15 cm (4″ to 6″) from the bridge of the patient's nose. Then the nurse would ask the patient to first look at the object, then at a distant object, then back to the object being held. The pupil normally constricts when looking at a near object and dilates when looking at a distant object. To test for convergence, the nurse would darken the room and ask the patient to look straight ahead. The nurse would then bring the penlight from the side of the patient's face and briefly shine the light on the pupil, observing the reaction. When testing convergence the nurse would hold a finger about 6″ to 8″ from the bridge of the patient's nose and move it toward the patient's nose.
The nurse is caring for an 88-year-old male admitted 2 days ago for dehydration. The nurse brings the client his breakfast tray and notes that the client appears to be having difficulty understanding what she is saying to him today. Which nursing action is most appropriate? a) Ask the client if he left his earplugs in his ears. b) Use facial expressions and sign language to communicate. c) Check the client's ear canals for cerumen. d) Speak to the elderly client in a high-frequency tone of voice.
c) Check the client's ear canals for cerumen.
Which technique would a nurse use to assess skin turgor? a) Indent area with fingertips b) Use a special type of lighting c) Touch the area to detect moisture d) Lightly pinch a fold of skin
d) Lightly pinch a fold of skin Skin turgor is assessed by lightly pinching a fold of skin and allowing it to return to its shape when released.
To assess a client's visual accommodation, the nurse has the client: A. stand 20 feet from Snellen chart B. sit still while a penlight is shined at the pupil C. look straight ahead with one eye covered D. look at a close object, then at a distant object
look at a close object, then at a distant object. Explanation: Accommodation can be tested by having the client look at a close object and then look at a distant object.
